Acta Dermato-Venereologica 99-2CompleteContent | Page 33

244 SHORT COMMUNICATION A Case of Generalized Interstitial Granuloma Annulare and Arthritis Associated with Breast Cancer Ariane CLAPÉ 1 , Clélia VANHAECKE 1 *, Anne DURLACH 2 , Philippe BERNARD 1 , Christelle JOUANNAUD 3 , Laurie KPODAR 4 , Bernard CRIBIER 5 and Manuelle VIGUIER 1 1 Department of Dermatology, Reims University Hospital, University of Reims Champagne-Ardenne, Avenue du general Koenig, FR-51092 Reims Cedex, 2 Biopathology, Hospital Maison Blanche, Reims University Hospital, 3 Department of Medical Oncology, Jean Godinot Institut, Reims, 4 Department of Rheumatology, Manchester Hospital, Charleville Mézières, and 5 Dermatopathology and Dermatology, Faculty of Medicine, University of Strasbourg, University Hospital of Strasbourg, Strasbourg, France. *E-mail: [email protected] Accepted Oct 3, 2018; E-published Oct 3, 2018 Granuloma annulare (GA) is a benign inflammatory skin disease of unknown origin, classically presenting with self-limited, skin-coloured to erythematous, papules with ring-shaped distribution with no epidermal changes, of- ten located on the dorsal surfaces of the hands and feet. Several clinical variants of GA have been described, including generalized GA, subcutaneous GA, and per- forating GA. GA shows typically palisading granulomas with a central zone of necrobiotic collagen surrounded by a palisade of histiocytes associated with mucin deposition. An interstitial histopathological pattern is also described, consisting of lymphohistiocytic in- filtrate scattered between and around collagen bundles and around blood vessels in the reticular and papillar dermis. Finally, subcutaneous histopathological patterns are also reported. With the exception of diabetes, no consistently as- sociated systemic disorder is identified in GA, and it is not usually considered as a paraneoplastic syndrome. We report here an unusual case of diffuse interstitial generalized GA in association with breast cancer. CASE REPORT A 45-year-old woman was referred to our dermatology unit with a 4-month history of an extensive rash with large erythematous pruritic papulous plaques (Fig. 1 a, b). The lesions initially invol- ved sun-exposed sites, and rapidly spread on the limbs, trunk and face with no eyelid involvement. The patient reported symmetrical polyarthritis of the ankles, knees and wrists, in association with high-grade fever, marked asthenia and 15 kg weight loss. No myalgia, motor deficit or synovitis was present. Physical examina- tion revealed a voluminous left mammary tumour T2 (5 cm) and palpable axillary lymph nodes N1 (6 cm). Her medical history was marked by diabetes mellitus (DM) and dyslipidaemia. Crea- tine kinase and aldolase concentrations were normal, antinuclear antibodies titre was 1:400 with speckled pattern. Tests for anti- extractable nuclear antibodies, anti-double-stranded DNA, anti J0-1 antibodies, rheumatoid factor and anti-cyclic citrullinated peptide antibodies were negative. There was no specific radiolo- gical damage in the peripheral joints. Cutaneous biopsies revealed a histiocytic infiltrate, with no multinucleated giant cells, in an interstitial and diffuse pattern from the papillary to the reticular dermis, with no interface dermatitis. Immunohistochemical stains showed diffuse CD68 + and CD163 + histiocytes (Fig. 2). The clinical presentation and histopathological findings led to the diagnosis of diffuse interstitial generalized GA. Breast biopsy revealed an invasive papillary carcinoma, SBR (Scarff Bloom Richardson) III, mitotic index 2, no embolus, oestrogen- receptor-positive (10%), progesterone-receptor-negative, human doi: 10.2340/00015555-3056 Acta Derm Venereol 2019; 99: 244–245 epidermal growth factor receptor type 2 (HER2) 1+. Whole-body 18-fluorodeoxyglucose positron emission tomography detected left axillary lymph node metastasis, but no distant metastasis. The patient was treated with a neoadjuvant chemotherapy, including 5 fluorouracil, epirubicin and cyclophosphamide (FEC 100 protocol) and transient oral morphine for joint pain. Complete resolution of arthritis and cutaneous manifestations was reported 2 months after the onset of chemotherapy, with no other specific treatment (Fig. 1c, d). No recurrence of the eruption was observed during the whole treatment (4 cycles of FEC 100, 12 perfusions of taxol, tumorectomy and axillary lymphadenectomy, radiotherapy) and under current hormonotherapy with a follow-up of 14 months. To date, the cancer is in remission. DISCUSSION The clinical presentation of this patient was atypical for GA, with large erythematous papulous plaques with an active border, involving a large skin surface. The lack of annular disposition was particularly puzzling; neverthe- less, non-annular lesions are usual in the generalized variety of GA (1, 2). The diagnosis of multicentric reti- culohistiocytosis (MRH) could also have been suspected because of concomitant polyarthritis and association with tumoural syndrome. Indeed, this rare systemic Fig. 1. Clinical photographys at the time of breast cancer diagnosis, showing symmetrically large erythematous papulous plaques involving: (a) chest; (b) thigh, after 2 cycles of neoadjuvant chemotherapy for breast cancer with residual post-inflammatory pigmentation involving the same locations as the initial lesions: (c) chest and (d) thigh. This is an open access article under the CC BY-NC license. www.medicaljournals.se/acta Journal Compilation © 2019 Acta Dermato-Venereologica.